• Friendly Visitor Volunteer Application

    Friendly Visitor Volunteer Application

    Please complete the below and upload any requested information
  • Date of Birth (due to program requirement, must be 18 year or older)*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • What city or cities are you available to volunteer in? Please check all that apply*
  • During my visit, I would enjoy:*
  • Are you comfortable entering a home with pet(s)?*
  • Are you comfortable with a senior with Alzheimer’s and related dementia (memory impairment)?*
  • Availability Information*
    Rows
  • Do you speak a second language other than English?*

  • Emergency Contact

  • Volunteer Documentation

  • Medical & History

  • If applicable, are you under any course of treatment/medication, which might limit your ability to perform certain types of work such as driving or handling any type of equipment?*
  • Have you ever been convicted, sentenced, placed on probation, pleaded guilty or “no contest” or agreed to deferred adjudication involving any crime related to illegal drugs, theft, fraud, or violence (e.g. Assault, battery, etc.)?*
  • Have you ever been convicted of found guilty of driving under the influence (DUI) or driving while intoxicated (DWI)?*
  • Has your drivers’ license ever been suspended or revoked?*
  • Are you seeking court-appointed volunteer hours?*

  • Background Check Requirement

    In the safe keeping of our seniors and community, a live scan background check is mandatory to be a Friendly Visitor Volunteer. You may have completed an online Sterling Volunteer background check in the past but the Sterling background check is not valid for the Friendly Visitor prorgram. Please complete as soon as possible so we can proceed with your application. Live Scan results from other organizations cannot be shared with Age Well, so a new Live Scan must be completed for this program.

     

  • Do you authorize Age Well Senior Services to complete a Live Scan Background Screening?*

  • Confidentiality Statement

    Please initial
  • In accordance with Age Well Senior Services, Inc., policy, I agree to keep confidential any and all information regarding Age Well Senior Services program participants and clients. This includes, but is not limited to, name, address, phone number, donation activity (anything pertaining to donations), medical information, and/or any other information that is in any way identifiable to Age Well Senior Services, Inc., program participants.*

  • Hold Harmless and Release of Liability Agreement

    Please initial
  • While volunteering for Age Well Senior Services, Inc., I hereby assume all responsibility for any and all risk of property damage or bodily injury that I may sustain while participating in any voluntary effort associated with Age Well Senior Services, Inc. including the use of equipment and facilities of Age Well Senior Services, Inc. Further, I agree to indemnify and hold harmless Age Well Senior Services, Inc., the Board of Directors, and their officers, employees and agents from any liability, loss or expenses resulting from any claim or litigation arising from my personal participation in the Volunteer Program*

  • Elder Abuse

    Please initial
  • While volunteering for Age Well Senior Services, Inc., I agree to report any reasonable suspicions of elder abuse* of Age Well clients directly to the Site Manager. Types of abuse may include physical abuse, sexual abuse, neglect by others, financial abuse, abandonment, isolation, abduction, or other treatment with resulting physical harm, pain, or mental suffering. In addition, self- neglect in form of health and safety, malnutrition/dehydration should also be reported.*

  • Guests (Anyone accompanying a volunteer that has not completed a volunteer application)

    I will be held responsible for guest(s) that accompany me and I understand that I will be held responsible for their adherence to Age Well policies.
  • Agree or Disagree*

  • Children (anyone under 18 years)

    If I choose to take children with me during my Friendly Visit, I will be responsible for their behavior and their safety. I will get permission from the FV program manager AND the senior prior to bringing any children along with me.
  • Agree or Disagree*

  • Pets

    No animals are allowed with me during my Friendly Visit. Exception only for ADA approved service dog along with permission from the FV program manager AND the senior prior to bringing any ADA service dog along with me. .
  • Agree or Disagree*

  • Volunteer Commitment

    It has been explained that I have certain responsibilities as a volunteer and will as such make commitments to the program(s) for which I am volunteering. If I am unable to fulfill a commitment, I will notify the FV manager as soon as possible so that a suitable replacement can be found.
  • Agree or Disagree*

  • Photo & Media Release

    I __do__do not grant permission to Age Well Senior Services, Inc. to use my image (including, but not limited to, photos and video in social media platforms such as Facebook and Instagram and the Age Well website.
  • Do you grant permission?*

  • Email Release

    I __do__do not grant permission to Age Well Senior Services, Inc. to send emails to the email address on file.
  • Do you grant permission?*

  • VOLUNTEER PROGRAM CODE OF CONDUCT

  • Please follow this Code of Conduct to help avoid any situations that compromise the integrity, independence, and reputation of Age Well Senior Services, Inc. This Code is designed to work alongside your own good judgment, as it is impossible to anticipate every potential situation.

    All Age Well Senior Services (AWSS), Inc., volunteers must adhere to the following:

    1. Gifts and Gratuities: A volunteer may not accept personal gifts, substantial gratuities, or cash from a client, participant, or vendor to avoid conflicts of interest or the appearance of impropriety.
    2. Conflict of Interest (COI): Volunteers must avoid situations where personal interests conflict with the mission and responsibilities of AWSS. Volunteers may not conduct private business, distribute commercial sales pitches, promote outside products or services, or represent personal or external business interests while acting in their volunteer capacity.
    3. Confidentiality and Privacy: Volunteers must maintain the strict confidentiality and privacy standards of AWSS.
    4. Data Protection: A volunteer may not distribute, share, disclose, or reuse client information, addresses, contact details, or proprietary organizational data outside of authorized AWSS channels.
    5. Documentation Compliance: Volunteers explicitly agree to keep all required documentation, credentials, background check renewals, training certifications, and personal contact information completely accurate and up to date, and will promptly update any documentation when requested by staff.
    6. Training and Orientation: Volunteers agree to participate in all scheduled initial and ongoing training programs.
    7. Professional Presentation and Safety: Volunteers agree to wear appropriate attire while volunteering, including closed-toe shoes when working in the kitchen or designated operational areas.
    8. Respectful and Inclusive Environment: Volunteers will treat all clients, participants, staff, and fellow volunteers with respect, dignity, and courtesy, fostering an environment free from discrimination, bullying, or harassment of any kind.
    9. Operational Compliance: Volunteers must work in support of their supervisor, comply with all organizational policies, and abide by program regulations and applicable laws.
    10. Drug and Smoke-Free Workplace: AWSS, is a strictly smoke-free (including vaping) and drug-free work and volunteer environment.
    11. Grounds for Dismissal: Volunteers may be dismissed for reasons including, but not limited to, disrespectful or harassing conduct towards seniors, volunteers, or staff, breach of confidentiality, conflicts of interest, failure to keep mandatory documentation up to date or failure to comply with staff requests for updates, or actions that bring discredit to the organization.

  • VOLUNTEER COMPLAINT & GRIEVANCE POLICY

  • Volunteer Documentation - Upload

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  • Volunteer Training

    Emergency Situations
  • Image field 182
  • I have read and reviewed the above training document*

  • Complete Application

    I certify that all answers given by me on this application or any other accompanying or required documents are true, accurate and complete. The falsification, misrepresentation or omission of facts will be cause for denial or removal of my volunteer application/status, regardless of when or how discovered. Volunteer Placement is subject to the availability and discretion of the Agency.
  • Today's date:*
     - -
    2 digit month, 2 digit day, 4 digit year

  • The complaint and grievance procedure is an opportunity for participants to express their concerns or dissatisfaction with the services and allow for an appropriate resolution of any such complaint or grievance. For grievances filed by non-English speaking participants, a bilingual staff member or volunteer will be available to facilitate the grievance process.

    1. Complaint Procedure: A complaint is an oral or written statement of dissatisfaction.

      A. Complaints can be directed to the VP Communications and Operations at the administrative office: Age Well Senior Services, Inc., 23101 Lake Center Drive, Suite 325, Lake Forest, CA 92630

      B. Upon receiving a complaint, the Vice President of Communications & Operations will assign the complaint to an appropriate staff member for investigation and action. Please address the service to which the complaint is in reference: Meals on Wheels/Case Management/Senior Center Location.

      C. If a solution is found by the Project staff and agreed to by the participant within twenty (20) working days of the complaint arriving at Age Well's administrative office, the complaint is resolved.

      D. If more than 20 days will be required to address the complaint, the VP of Communications & Operations will advise the participant in writing within 20 days and will provide an estimate of when the complaint will be resolved, not to exceed 45 days from the date when the complaint was received at Age Well's administrative office.

    2. Grievance Procedure: A grievance is any complaint that cannot be resolved to the participant's satisfaction within the complaint system and which has been brought to the grievance level for further action.

      A. A participant may use the grievance process to appeal any unsatisfactory complaint resolution.

    3. Confidentiality of Information: Names of complainants are confidential and are protected from unauthorized disclosure without specific written approval of the participant or guardian, unless the person is authorized by law to receive it.

      A. Persons representing the news media will not be given any information or leads to the identification of the participant including photographs, unless the participant has given written consent.

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